High flow nasal oxygen and airway fires
Myron Yaster MD, Francis Veyckemans MD, and Genie Heitmiller MD
Can you imagine anything more frightening or as catastrophic as an airway fire? In today’s PAAD, Lyons et al.1 review the risks of an airway fire while using high flow nasal oxygen. As a reminder, the three essential elements needed for a fire to start and sustain itself are fuel (combustible material like an endotracheal tube, drapes, airway sponges/gauze, skin or hair), heat (an ignition source like electrocautery, laser, or a spark), and an oxidizer = oxygen.
When I first read this article, I wondered - how could a fire occur when using high flow nasal oxygen? Where was the fuel? Typically, in the OR, high flow nasal oxygen is used during rigid bronchoscopy, micro laryngoscopy, and during intubation for difficult airways, meaning there is no airway equipment in the mouth (“tubeless” anesthesia) that can ignite. As we will see, there is plentiful fuel, and fire is a real potential threat even without an airway in place.
There are several important key elements that require/demand practice BEFORE a fire occurs. This is definitely not something you can do well in the heat of the moment (no pun intended!). I would urge all of you, particularly in teaching hospitals and clinics, to practice what to do using SPA’s PediCrisis app version 2. It is the perfect cognitive tool for practicing the rescue algorithm (and of course, if you haven’t already downloaded it from the Apple or Android store, or from SPA’s website, do it now!).2 I used the app as a teaching tool whenever I did a T&As to review fire rescue and management 2 because many trainees are not aware that a leak around the tracheal tube increases oxygen concentration in the oropharynx.3,3b,4 The single most important step is to TURN OFF OXYGEN and disconnect the endotracheal tube from the circuit (or the circuit from the machine)! If oxygen is not turned off, the endotracheal tube will produce a jet of flame, as you can see in the videos below. One of the videos, by Dr. Max Feinstein, has a lot of good teaching points but a potentially fatal error. He recommends turning down the FiO2 and not turning the oxygen off and disconnecting the tube. This is simply wrong, and as can be seen in the other videos, can lead to disaster. Myron Yaster MD
Original article
Lyons C, Jonsson Fagerlund M. Airway fires during use of high-flow nasal oxygen: a cause for concern. Br J Anaesth. 2025 Apr;134(4):893-897. doi: 10.1016/j.bja.2024.12.021. Epub 2025 Feb 21. PMID: 40118580; PMCID: PMC11947558.
“High-flow nasal oxygen (HFNO) refers to the administration of heated and humidified oxygen via nasal cannula at typical flow rates of 30-70 L/minute. More than 80% of operating room fires occur at the head, neck, or upper chest of patients.5 Local oxygen concentration is further increased when surgical drapes impede air exchanges by theatre ventilation systems and cause oxygen to pool.6.”1 Lyons et al. point out that even though we don’t know the exact number of airway fires that occur while using HFNO, it does occur and “the potential sources of fuel can be diverse, including airway equipment; surgical instruments; antiseptic skin preparations; surgical drapes; clothing; dressings; and patient hair and skin.”1 In my own experience (MY), I had heard of OR fires caused by regular supplemental oxygen delivered by nasal cannula during eye surgery when the skin was prepped with alcohol or the cloth drapes did not allow free circulation of air. This also reportedly happened during plastic surgery on the face while using 3L nasal cannula supplemental oxygen, during which time the drapes caught fire resulting in a shoulder burn (GH).
“In 2023, the Australian and New Zealand College of Anaesthetists (ANZCA) issued a safety alert to remind anaesthetists that ‘great caution must be taken with HFNO use in the presence of an ignition source during airway and head and neck surgery. Guidance issued by ANZCA in 2024 states that ‘an oxygen air blender can be used if the oxygen concentration required is less than 30%’ but to ‘consider securing the airway’ if a higher concentration is needed.”1
Whether using an endotracheal tube, tubeless anesthesia, or performing a tracheostomy, if there is an ignition source, it makes sense to reduce the expired concentration of O2 to 25-30% or to room air (21%).7 The authors concluded: “Our understanding of the risks and benefits of HFNO use in anaesthetic practice remains primitive. Clinical research will incompletely characterise its safety profile as uncommon events are unlikely to be captured. When an anaesthetist encounters a complication that is severe or previously unrecognised, they should report their experience to manufacturers and regulatory bodies. The ability to learn from such an event will be maximised if the experience is shared with other clinicians, such as through a case report. These endeavours can feel personally and professionally uncomfortable, and might even be discouraged by institutions if the care delivered was suboptimal and at odds with manufacturer recommendations, but will help reduce the likelihood of future patients experiencing a similar event. We must do more to understand and reduce the rare but serious adverse events associated with use of HFNO in anaesthetic.”1
What do you think? What do you do in your practice? Send your thoughts and comments to Myron who will post in a Friday reader response.
PS: For an even deeper dive: https://www.openanesthesia.org/keywords/surgical-fires/?search_term=airway%20fire
References
1. Lyons C, Jonsson Fagerlund M. Airway fires during use of high-flow nasal oxygen: a cause for concern. British journal of anaesthesia 2025;134(4):893-897. (In eng). DOI: 10.1016/j.bja.2024.12.021.
2. Strupp KM, Mandler T, Papazian L, et al. The Use of the Society for Pediatric Anesthesia's Pedi Crisis 2.0 Mobile Application as an Educational Assessment Tool for Pediatric Anesthesiology Fellows: A Prospective, Randomized, Controlled Multi-Center Study. Anesthesiology 2025 (In eng). DOI: 10.1097/aln.0000000000005499.
3. Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating room fires: a closed claims analysis. Anesthesiology 2013;118(5):1133-9. (In eng). DOI: 10.1097/ALN.0b013e31828afa7b.
3 b. Kaddoum RN, Chidiac EJ, Zestos MM, Ahmed Z. Electrocautery-induced fire during adenotonsillectomy: report of two cases. J Clin Anesth 2006; 18:129-31
4. Jones TS, Black IH, Robinson TN, Jones EL. Operating Room Fires. Anesthesiology 2019;130(3):492-501. (In eng). DOI: 10.1097/aln.0000000000002598.
5. Standards UbtCo, Parameters P, Chicago I, et al. Practice Advisory for the Prevention and Management of Operating Room Fires: An Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013;118(2):271-290. DOI: 10.1097/ALN.0b013e31827773d2.
6. Culp WCJ, Muse KW. Preventing Operating Room Fires: Impact of Surgical Drapes on Oxygen Contamination of the Operative Field. Journal of patient safety 2021;17(8):e1846-e1850. DOI: 10.1097/pts.0000000000000665.
7. Remz M, Luria I, Gravenstein M, et al. Prevention of airway fires: do not overlook the expired oxygen concentration. Anesthesia and analgesia 2013;117(5):1172-6. (In eng). DOI: 10.1213/ANE.0b013e318298a692.